Monitoring Normal Monitoring Normal Operations Operations and the Line Operations and the Line Operations Safety Audit (LOSA): Safety Audit (LOSA): The Perspective of ICAO The Perspective of ICAO Captain Dan Maurino Captain Dan Maurino Flight Safety and Human Factors – ICAO Flight Safety and Human Factors – ICAO Royal Aeronautical Society Conference on Royal Aeronautical Society Conference on Mitigating Human Error Mitigating Human Error London, 15 October 2003 London, 15 October 2003
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Monitoring Normal Operations and the Line Operations Safety Audit (LOSA): The Perspective of ICAO Captain Dan Maurino Captain Dan Maurino Flight Safety.
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Monitoring Normal OperationsMonitoring Normal Operationsand the Line Operations and the Line Operations
Safety Audit (LOSA): Safety Audit (LOSA): The Perspective of ICAO The Perspective of ICAO
Captain Dan MaurinoCaptain Dan MaurinoFlight Safety and Human Factors – ICAOFlight Safety and Human Factors – ICAO
Royal Aeronautical Society Conference onRoyal Aeronautical Society Conference onMitigating Human ErrorMitigating Human Error
London, 15 October 2003London, 15 October 2003
System System designdesign
Baseline performanceBaseline performance
BaselineBaselineperformanceperformance
OperationalOperationalperformanceperformance
““PracticalPracticalDrift”Drift”
OperationalOperationaldeploymentdeployment
When the Book Goes Out of the WindowWhen the Book Goes Out of the Window
Raiding the Lost ArkRaiding the Lost Ark
NaturalNaturalPerformancePerformance
““Angel” Angel” PerformancePerformance
RegulatorRegulator NobodyNobodyLine Line
Checks Checks
LOSA LOSA
A Day at the OfficeA Day at the OfficeTo achieve daily safety and production goals, flight crews mustTo achieve daily safety and production goals, flight crews must
Threat Threat ManagementManagement
Error ManagementError Management
Undesired Aircraft Undesired Aircraft State ManagementState Management3 Manage aircraft deviations
Not flight crew errorsNot flight crew errors Not deficiencies in the systemNot deficiencies in the system
Factors external to the flight deck that Factors external to the flight deck that increase complexity of flight operationsincrease complexity of flight operations
Must be managed by the flight crewMust be managed by the flight crew Threats = Red flagsThreats = Red flags
LOSA: Non-Conforming Approaches Percent Improvement Over 1996 (Approaches Outside Required
1000 ft or 500 ft Window)
1996 - ALL 1998 - L.A. 1999 - PACIFIC 2000 - ALL
Reduced
49% Reduced59%
Reduced
59%
LOSA 1996 vs. 2000 Checklist ErrorsLOSA 1996 vs. 2000 Checklist Errors
11% of the flights9% of the flightsLOSA 2000
385 flights
Missed itemsWrong response to a challengeWrong checklist performedUnintentional checklist omission
Performed from memoryNonstandard phraseologySelf initiated
Not called “complete”Intentional checklist omission
Checklist Error
Examples
33% of the flights
Flights with protocol checklist errors
9% of the flights
Flight with unintentional checklist errors
LOSA 1996389 flights
LOSA 2000 indicated a significant drop inLOSA 2000 indicated a significant drop in protocol protocol checklist errorschecklist errors while while unintentional unintentional checklist errors have remained unchangedchecklist errors have remained unchanged
Threat & Error Management Model (Doc 9803)Threat & Error Management Model (Doc 9803)
Highest riskHighest riskphase of flightphase of flight
Briefing the ApproachBriefing the Approach
Crews who brief Crews who brief before before TOD commit TOD commit 1.6 times less 1.6 times less errorserrors during descent, approach and land than during descent, approach and land than crews who brief crews who brief afterafter TOD TOD
Landing runway changes occurred Landing runway changes occurred 8 percent8 percent of the of the timetimeTraining point: brief approach prior TODTraining point: brief approach prior TOD
TEM Model - Training ToolTEM Model - Training Tool
CRM, CRM, circacirca 2003 2003 Beyond behavioural stereotypesBeyond behavioural stereotypesOperational performanceOperational performanceDevelop and support threat and error management Develop and support threat and error management
competenciescompetencies
The bottom line is safe and efficient The bottom line is safe and efficient operational performance, operational performance, notnot CRMCRM
SMS Data TriangleSMS Data Triangle
Normal Normal Operations Operations
FDAFDA Voluntary Voluntary ReportingReporting
A A Casque BleuCasque Bleu Perspective Perspective
LOSA: a LOSA: a tooltool to capture systemic data to capture systemic data NOTECHS: a CRM evaluation templateNOTECHS: a CRM evaluation template LOSA: context and cognitionLOSA: context and cognition NOTECHS/CRM: behavioursNOTECHS/CRM: behaviours CRM: just one piece of the infinitely broader CRM: just one piece of the infinitely broader
information picture developed from LOSAinformation picture developed from LOSA A situation, generated by misperceptions and A situation, generated by misperceptions and misinformation, that must be put behindmisinformation, that must be put behind